1. Greater Columbia Accountable Community of Health
Yakima Valley Conference of Governments

2. Washington State vision for creating healthier communities and a more sustainable health care system by:
Building healthier communities through a collaborative regional approach
Ensuring health care focuses on the whole person
- Executive branch support: Healthier Washington is the Governor’s vision; and state agency partners—including DOH and DSHS—are instrumental in this work.
- Legislative support: They passed legislation moving the innovation plan forward, and bridge funding to start the work.
- Federal support: A $65 million innovation grant to propel Healthier Washington from vision to reality.
is the year when the state innovation plan moves from a plan two years in the making to reality.
Three Transformative Strategies:
1. Drive value-based purchasing across the community, starting with the State as “first mover.”
2. Improve health overall by building healthy communities and people by prioritizing prevention and early mitigation of disease throughout the life course.
3. Improve chronic illness care through better integration of care and social supports, particularly for individuals with physical and behavioral co-morbidities.
Improving how we pay for services 2
Better Health, Better Care, Lower Costs

3. Healthier Washington recognizes that health is more than health care.
- Health systems transformation is not just health care reform--this really is about all the systems that affect health, not just medical care.
- The current system:
- Separates the “head” from the “body” —no integration between services for physical health, mental health and chemical dependency.
- Focuses on volume of services provided, not quality of outcomes.
- Is expensive, and getting more so, without producing better results.
Health is more than health care.
HW is grounded in an understanding that health is more than health care – that 80% of the factors that affect a person’s health occur outside of the health care system.
Improving people’s health outcomes (and lowering costs) will depend on addressing those factors and linking supports for them to the health care delivery system.
- Health encompasses community (nutritious food, housing, public health), system supports (measurement, consumer engagement, workforce development) and health & recovery efforts (mental health, long-term care, oral health).
Adapted from: Magnun et al. (2010). Achieving Accountability for Health and Health Care: A White Paper, State Quality Improvement Institute.. Minnesota. 3
Better Health, Better Care, Lower Costs

4. Healthier Washington is more than the State Innovation Models (SIM) grant…
2014 Legislation:
House Bill 2572
Senate Bill 6312
Medicaid Transformation Potential demonstration project within Medicaid
- In addition to WA state legislation and a grant from CMMI, Medicaid Transformation activities, such as the 1115 Global Medicaid Waiver, will support Healthier WA initiatives.
- Implementation tools:
- SIM grant: $65 million over 4 years
- State budget: “Bridge” funding to move forward while awaiting word on SIM grant (July 2014-June 2015)
- In-kind and philanthropic support
bills to support Healthier Washington: HB 2572: Performance measures, communities of health, all-payer claims database and SB 6312: Integration of physical and behavioral health
SIM Grant:
$65 million over 4 years from the federal government 7
Better Health, Better Care, Lower Costs

5. Accountable Communities of Health
Healthier Washington is bringing together providers, social service organizations, health plans, hospitals, county governments, tribes, and others through nine regional Accountable Communities of Health (ACHs).
ACHs will support communities in making informed decisions on health needs and priorities.
- A foundational element of Washington state’s transformation strategy is the development of regionally based, voluntary collaborative called “Accountable Communities of Health” (ACHs) to drive integrated delivery of health and social services and improve population health.
- ACHs will provide the forum, organizational support, and State-community partnership to achieve transformative results through collaboration. Within regions, and across the state, ACHs represent collaborative decision-making across multiple sectors and systems to align actions to achieve healthy communities and populations. ACHs are the accelerator/coordinator of regional best practices, lessons learned and shared challenges to drive health systems transformation focusing on population health, social determinants of health, clinical-community linkages and whole person care. Community and regional impact, including regional purchasing strategies, starting with Medicaid.
- ACH infrastructure and governance grounded in the “collective impact” model
- Collective Impact structure: common agenda, shared measurement, mutually reinforcing activities, continuous communication, and backbone support
- Collective Impact is the commitment of a group of important actors from different sectors to a common agenda for solving a specific social problem.
A Healthier WA will see engaged communities focused on community health and wellness, whole person care, and partnering with the state delivery system improvement, including value based purchasing.
Timeline: Iterative development process over the entirety of the SIM grant. Goal for statewide designation for all ACHs by the end of 2015.
We’re well into ACH design and implementation, but early in the four-year process. We still have a lot to learn in partnership with our communities.
COH Planning (2572) in 2014 provided a very valuable learning opportunity for the state and for communities as they consider the newly established RSAs and future ACH development. COH planning regions informed the competitive selection of two pilot regions based on maturity and identification of regional pilot projects.
Two Pilots were selected (2572) in 2015 and these two regions just recently achieved official ACH designation (North Sound and Cascade Pacific Action Alliance)
Seven Design regions, of which SWWA is one, are working on the following:
Governance and Organizational Structure
Community Engagement and Multi-sector Representation
Regional assessment and asset inventories 9
Better Health, Better Care, Lower Costs

6. A Forum for regional collaborative decision making

7. Community Empowerment & Accountability
Accountable Communities of Health (ACHs) will:
Provide a multi-sector voice for delivery system reform, shared health improvement goals and regional purchasing strategies.
Serve as a forum for regional collaborative decision-making to accelerate health system transformation, focusing on social determinants of health, clinical-community linkages, and whole person care.
Accelerate physical and behavioral health care integration through financing and delivery system adjustments, starting with Medicaid.

8. Medicaid Transformation
Those of you who read the concept paper and draft application are familiar with the story of John. John was a recent Apple Health enrollee, a young adult with a bipolar disorder and diabetes.
As described in the concept paper, he has a number of challenges in managing his health. Most of these stem from the fact that his two diagnoses are being treated by different people in different systems that are not connected; sometimes they don’t even have critical information about the other medications he’s been prescribed.
The fragmented care, particularly during times when he has transitioned out of acute care settings, has also had an impact in how engaged John is in his own recovery.
And this is in a system where every person involved in John’s care – physicians, counselors, and case managers – are all committed and doing their best to help John get healthy.
In our current system, you could multiply John’s situation thousands of times over to people in all sorts of situations – people you’ve heard giving testimony or met back at home in your districts.
The people who use our system most heavily, who suffer from non-medical issues as well, like homelessness, and those who are more reflective of the average…from a mother with asthma who has difficulty getting to her medical appointments to a retired person with mobility issues who is struggling to stay in her home. 10
Better Health, Better Care, Lower Costs

9. Current System Transformed System
Medicaid Transformation
Current System
Transformed System
Fragmented clinical and financial approaches to care delivery
Integrated systems that deliver whole person care
Disjointed care and transitions
Coordinated care and transitions
Disengaged clients
Activated clients
Capacity limits in critical service areas
Optimal access to appropriate services
Individuals impoverish themselves to access long term services and supports (LTSS)
Timely supports delay or divert need for Medicaid LTSS
Inconsistent measurement of delivery system performance
Standardized performance measurement with accountability for improved health outcomes
Volume-based payment
Value-based payment
The changes in recent years – and the years to come that make transformation as a road to sustainability essential.
With ACA, Medicaid enrollment has grown by more than 50 percent. Washington is a leader and has cut the state’s uninsured rate in half.
But this also means our current system is serving more people – in particular, the 550,000 new adult enrollees that it was not previously serving, individuals with different care needs than the children and people with disabilities it was serving before.
The potential 1115 Global Medicaid Waiver demonstration in WA state is an opportunity to bring the Healthier Washington vision to scale for Apple Health, giving us the flexibility to use Medicaid funds to pay for what works. 12
Better Health, Better Care, Lower Costs

10. Washington’s Medicaid Transformation Goals Achieving the Triple Aim
Reduce avoidable use of intensive services and settings
Improve population health
Accelerate the transition to value-based payment
Ensure that Medicaid per-capita cost growth is below national trends
Better Health, Better Care, Lower Costs 10

11. Delivery System Reform
Waiver Initiatives
Initiative 1
Initiative 2
Initiative 3
Transformation through Accountable Communities of Health
Enable Older Adults to Stay at Home; Delay or Avoid the Need for More Intensive Care
Targeted Foundational Community Supports
Delivery System Reform
Benefit: Medicaid Alternative Care (MAC)
Benefit: Supportive Housing
Community based option for Medicaid clients and their families
Services to support unpaid family caregivers
Individualized, critical services and supports that will assist Medicaid clients to obtain and maintain housing. The housing-related services do not include Medicaid payment for room and board.
Each region, through its Accountable Community of Health, will be able to pursue projects that will transform the Medicaid delivery system to serve the whole person and use resources more wisely.
Benefit: Tailored Supports for Older Adults (TSOA)
Benefit: Supported Employment
For individuals “at risk” of future Medicaid LTSS not currently meeting Medicaid financial eligibility criteria
Primarily services to support unpaid family caregivers
Services such as individualized job coaching and training, employer relations, and assistance with job placement.
Transformation Projects
Medicaid Benefits/Services

12. Domains Transformation Framework
The framework is a high-level overview of the strategies necessary to achieve the desired outcomes under each domain.
Domain 1: Health Systems Capacity Building*
Workforce and non-conventional service sites
Primary care models
Data collection and analytic capacity
* All Domain 1 projects must demonstrate a direct connection to Domains 2 or 3
Domains
Domain 2: Care Delivery Redesign
Bi-directional integration of care
Care coordination
Care transitions
Domain 3: Prevention and Health Promotion
Chronic disease prevention and/or management
Maternal and child health 12

13. Medicaid Population: Greater Columbia ACH
SUMMARY GROUP NAME
Statewide Total
GCACH
ADULTS
CHILDREN
TOTAL
2016
County Population
OFM
April 1, 2016
AEM Expansion Adults
298 64
Asotin
22,150
Apple Health For Kids
797,098
524
131,598
132,122
Benton
190,500
*18%
Elderly persons
73,717
7,447
Columbia
4,050
*1%
Family (TANF) Medical 33 4 1 5
Franklin
88,670
Family Planning
11,754
1,737 86
1,823
Garfield
2,200
Former Foster Care Adults
2,134
248 34
282
Kittitas
43,710
Foster Care
29,375 35
3,272
3,307
Klickitat
21,270
*.45%
Medicaid CN Caretaker Adults
137,374
18,088
Walla Walla
60,730
*2.5%
Medicaid CN Expansion Adults
596,958
70,133
Whitman
47,940
*10%
Other Federal Programs 21
Yakima
250,900
Partial Duals
60,123
6,849
Total GCACH Pop 
732,120  
*.9%
Persons with disabilities
149,983
14,017
3,497
17,514
Total GCACH Pop Medicaid 
260,535 
*1.9%
*.5%
Pregnant Womens Coverage
17,242
2,901
*.4%
Total WA State 2016
1,876,110
122,047
138,488
260,535
26.5%
*17%
*18.9%
*35%

14. Greater Columbia Governance Structure

15. Accountable Community of Health (ACH) History
Basic Idea: Everyone moving into the same direction at the same time to impact some of our seemingly intractable health issues.
A regional health improvement coalition of independent organizations
An Accountable Community of Health is a group of leaders from a variety of sectors in a given geographic area with a common interest in improving health. Participating, among others, are health and long-term care providers, health insurance companies, public health agencies, school districts, criminal justice agencies, non-profit social service agencies, legal services organizations, tribes, and philanthropic agencies. With support from the state, they are voluntarily organizing to coordinate activities, jointly implement health-related projects, and advise state agencies on how to best address health needs with in their area. They are not intended to duplicate or replace existing services.
Mission: The mission of the Greater Columbia Accountable Community of Health is to advance the health of our population by decreasing health disparities, improving efficiency of health care delivery, and empowering individuals and communities through collaboration, innovation, and community engagement.
Accountable Community of Health (ACH) History
7/2014 – Launch of “Communities of Health” (COH)
1/13/ State Designation Achieved “Accountable Community of Health”
7/29/16 – Submitted Regional Health Improvement Plan
8/8/16 – SIM Project Approved

16. Backbone Organization
BFCHA
Carol Moser
Aisling Fernandez
Eastern WA University
Dr. Patrick Jones
Board of Directors
Public Health
Hospital
FQHC
Healthcare Provider
Mental Health Provider
CBO/FBO
Social Services
Local Government
Columbia County
Martha Lanman
Yakima Memorial Hospital
Eddie Miles
Tri-Cities Community Health
Martin Valadez
Sunnyside Community Hospital
Brian Gibbons
Comprehensive Mental Health
Ed Thornbrugh
Catholic Family and Child Services
Darlene Darnell
SE WA Aging and Long Term Care
Lori Brown
GCBH Executive Director
Ken Roughton
Education
Philanthropy
Managed Care
Housing
Business
Tribes
Public Safety
Consumer
Transportation
ESD 123
Les Stahlnecker
Three Rivers Community Foundation
Carrie Green
Coordinated Care
Andrea Tull
Yakima Neighborhood Health
Rhonda Hauff
TBD
Yakama Nation
Frank Mesplie
Kittitas Fire
John Sinclair
Northwest Justice Project Jefferson Coulter
People for People
Madelyn Carlson

17. Greater Columbia Accountable Community of Health
Collective Impact Model
Committees
Backbone Organization for Greater Columbia Accountable Community of Health
Board of Directors
Care
Coordination
Partners/Sectors
Community Members
Public Health
Hospital
FQHC
Healthcare Provider
Mental Health Provider
CBO/FBO
Social Services
Managed Care
Philanthropy
Education
Local Government
Public Safety
Tribes
Business
Housing
Consumer
Transportation
Other
Leadership Council
Behavioral Health
Oral Health
Healthy Youth & Equitable Communities
Diabetes & Obesity
Assessment & Planning Committee
Executive Committee
Nominating Committee
Finance Committee
By-Laws Committee
Communications Committee
Strategic Issues Committee
Data Com
Priority Workgroups and Committees

18. Guiding Principles Promote a culture of health and health equity
7 local community forums (county-based) that interact with a regional coordinating council
4 core values (operating principles)
Guiding Principles
Promote a culture of health and health equity
Facilitate a regional population health approach
Engage the community
Focus on prevention and early intervention
Ensure strategies are data-informed, aligned, culturally competent, and sustainable

19. Overarching Strategies in RHIP

20. Access to exercise opportunities: Lower than the State!
Increased physical activity is associated with lower risks of type 2 diabetes, cancer, stroke, hypertension, cardiovascular disease, and premature mortality, independent of obesity. The role of the built environment is important for encouraging physical activity. Individuals who live closer to sidewalks, parks, and gyms are more likely to exercise.

21. Dental Workforce Shortages
Untreated dental disease can lead to serious health effects including pain, infection, and tooth loss. Although lack of sufficient providers is only one barrier to accessing oral health care, much of the country suffers from shortages.

22. Median Household Income, 2016
Median household income is a well-recognized indicator of income and poverty and is strongly correlated with children in poverty. Poverty can result in an increased risk of mortality, prevalence of medical conditions and disease incidence, depression, intimate partner violence, and poor health behaviors.
Note: YIN = Yakama Indian Nation

23. Shortage of Mental Health Providers
Thirty percent of the U.S. population lives in a county designated as a Mental Health Professional Shortage Area. As the mental health parity aspects of the Affordable Care Act create increased coverage for mental health services, many anticipate increased workforce shortages.i

24. State Innovation Model (SIM) Project
Care Transitions: Coordinating the medical and social services needed to improve patients' likelihood of readmitting to the hospital within 30 days of their last hospital stay.
Working with Consistent Care Services, the Pilot will identify 40 patients (25 Kadlec, 15 Trios) and transition their care into their home with follow-up visits from WSU Nursing students.

25. For more information, contact: Carol Moser cmoser@greatercolumbiaach
For more information, contact: Carol Moser Website:
Thank you for the opportunity to discuss Healthier WA with you today, and we look forward to a continued partnership as Healthier WA further develops throughout the state.
Thank you!